Failure of bretylium to suppress inducible ventricular tachycardia

Five patients with recurrent, life-threatening ventricular arrhythmias were given bretylium tosylate intravenously for a minimum of 4 days. Arrhythmias were not related to acute ischemia in any patient. Four patients had inducible ventricular tachycardia, and one patient had inducible ventricular fibrillation requiring cardioversion while taking no medications. Programmed electrical stimulation was then repeated to assess the ability of bretyllum to suppress inducible ventricular tachycardia. Bretylium tosylate, at a mean dose of 2.3 mg intravenously per minute, did not suppress inducible ventricular arrhythmias in any patient. Rapid ventricular tachycardia was induced in all patients, and ventricular fibrillation was induced in one patient. Two patients required external cardioversion to terminate their arrhythmias. Bretylium tosylate, given in relatively large doses chronically, did not suppress inducible ventricular arrhythmias in these five otherwise drug-refractory patients with chronic recurrent ventricular tachycardia. This failure to suppress inducible ventricular arrhythmias cannot be attributed to the initial catecholamine release which occurs in the first hour or two after the drug is administered.     

Preparing Long-Term Care Staff to Meet the Needs of Aging Persons With Serious Mental Illness

ObjectivesIndividuals with serious mental illness (SMI; schizophrenia spectrum disorders and affective psychoses) are increasingly aging into older adulthood and are overrepresented in residential long-term care settings. The present study aimed to examine the preparedness of staff in these settings to care for individuals with SMI.DesignA multidisciplinary US Department of Veterans Affairs (VA) workgroup of professionals with expertise in geriatric mental health collected voluntary feedback via online questionnaire as part of a quality improvement project.Setting and ParticipantsRespondents were mental health providers (N=51) embedded in VA nursing homes called Community Living Centers (CLCs).MeasuresThe questionnaire contained multiple-choice, Likert-type scale, and open-ended questions regarding the opportunities and challenges associated with caring for Veterans with SMI in CLCs.ResultsRespondents identified a lack of training of front-line staff as a key challenge in providing high-quality care to residents with SMI. Specifically, respondents indicated a need to increase staff knowledge about SMI symptoms and diagnoses, to improve staff communication and interactions with residents with SMI, and to decrease mental illness stigma among staff.Conclusions/ImplicationsThe present study revealed significant areas of training need for front-line staff in nursing homes. Many perceived staff training needs overlap with the knowledge and skill set required to provide high-quality dementia care. Integrating training regarding the care of residents with SMI into dementia care training efforts may be a fruitful future direction. Strategies for this and a suggested curriculum are provided.     

Changes in the ST waveform of the fetal lamb electrocardiogram with hypoxemia

The ST waveform of the fetal electrocardiogram (ECG) was examined in 10 chronically instrumented fetal lambs from 115 days to term. Averaged ST waveforms were plotted at 5-minute intervals in six fetuses for 2 to 22 days. No diurnal or other rhythms were seen. To correct for changes in signal gain the amplitude of the T wave was measured relative to the amplitude of the QRS complex. The T/QRS ratio was normally less than 0.30. Persistently elevated ST waveforms with a T/QRS range 0.32 to 0.65 preceded fetal death by some days in three fetuses and were associated with anemia and/or hypotension in a further three. In these animals hypoxia produced a further rise in the ST waveform (mean T/QRS, from 0.48 to 0.81) and all died during labor. In lambs with a normal ST waveform there were differences in the response to hypoxia over 1 hour for a similar fall in Po₂. In eight experiments the ST segment and T wave increased (mean T/QRS, from 0.17 to 0.59) and promptly reverted to normal with normoxia. There was a significant rise in mean arterial blood pressure, plasma lactate, and glucose and a fall in pH. In four experiments there was little change (mean T/QRS, from 0.19 to 0.25), with a small rise in plasma lactate suggesting that these lambs were able to maintain aerobic myocardial metabolism. Overall there was a strong correlation of the T/QRS ratio to the rate of rise of lactate. These findings complement previous results in the acute fetal lamb preparation and suggest that ST waveform elevation expressed as the T/QRS ratio identifies a change to anaerobic myocardial metabolism.     

Assessment of menopausal symptoms in different transition phases using the Greene Climacteric Scale among rural women of North India

Background: Menopause is the universal physiological process of women’s midlife and exhibits a wide variety of symptoms. However, there is little data on the menopausal symptoms and factors associated with their severity among rural Indian women.

Aim: To evaluate the prevalence of menopausal symptoms during the different transition phases of menopause among rural women of North India.

Subjects and methods: This cross-sectional study consisted of 351 women aged 35–55?years (mean age 44.6?years) residing in rural areas of North India. A structured questionnaire was used to collect data regarding menopausal status, demographic profile and reproductive history of the participants. Frequency and severity of menopausal symptoms were evaluated using the Greene Climacteric Scale in different stages of menopause. All statistical procedures were accomplished using SPSS version 19.0.

Results: In the present study the mean ages of attainment of menarche and menopause were 14.3?years and 47.2?years, respectively. Mean score of total Greene Climacteric Scale was highest among perimenopausal women (16.12?±?8.1) over post-menopausal (14.78?±?7.3) and pre-menopausal women (11.08?±?6.1). Logistic regression analysis revealed that advancing age, low educational attainment, low socioeconomic status, menopausal status, later age at menarche and higher BMI were all associated with more severe menopausal symptoms.

Conclusion: The climacteric symptoms were more prevalent among women who were perimenopausal followed by post-menopausal women and were the lowest in pre-menopausal women. Age, menopausal status, socio-economic status, and reproductive factors significantly influenced the severity of menopausal symptoms.     

Acute renal failure and renal tubular squamous metaplasia following treatment with streptozotocin

Nephrotoxicity, in the form of transient proteinuria, azotemia, abnormalities of tubular function, and acute renal failure, is the major toxic condition following administration of streptozotocin. The renal morphologic and ultrastructural abnormalities associated with streptozotocin remain poorly defined. We describe a patient with metastatic islet cell tumor of the pancreas who was treated with 16 weekly courses of 1 g/m2 of streptozotocin without marked change in renal function. Following a six-week hiatus without change in renal function, a single course of 1 g/m2 of streptozotocin was administered and resulted in acute renal failure. Light microscopic examination of the kidneys showed irregularly dilated renal tubules lined by low cuboid epithelium. The cells were pleomorphic and showed some mitoses. Nuclei were irregular and variably hyperchromatic. Electron microscopic examination disclosed large aggregates of fine microfilaments in the proximal convoluted tubules and collecting ducts. Microfilament aggregates were both free in the cytoplasm and membrane bound. Microfilaments were proved to be tonofilaments by the demonstration of keratin within the epithelium, using the immunoperoxidase method. These data suggest that squamous metaplasia may be an important part of streptozotocin renal toxicity, and the suggestion is made that they may be an antecedent of neoplastic change.     

Infection surveillance and control in the severely traumatized patient

Among severely traumatized patients, infection is second only to head trauma as the leading cause of death. Few studies have defined the infections that occur, the risk factors involved, or the appropriate means of evaluating these patients. In our trauma unit, daily infection surveillance included clinical evaluation of every patient and all microbiologic data. In addition, prophylactic and therapeutic antibiotics were directly under our control. Over a two year period 2,368 patients were admitted, most arriving directly from the scene by helicopter. The over-all mortality was 20 percent. In this setting, 639 nosocomial infections occurred in 381 patients of whom 14 percent died of their infection. Sites of infection in percent of total and of bacteremia (given in parentheses) were urinary tract 18 (3), pneumonia 15 (19), empyema 11 (11), phlebitis 12 (17), primary bacteremia 10 (21), surgical wound 19 (8), intraabdominal 8 (11), CNS 7 (5), sinusitis 5 (0), arterial lines 2 (4) and other 3 (1). Over-all 44 percent of infections were bacteremic. Organisms involved in nosocomial infections as percent of total and in bacteremias (given in parentheses) were coagulase-positive Staphylococcus 24 (39), other gram-positive cocci 13 (8), Escherichia coli 13 (9), Klebsiella 19 (13), Pseudomonas 13 (11), Enterobacter 8 (6), Proteus 4 (5), anaerobes 3 (1) and other organisms 12 (8). Most infections were directly related to an invasive procedure.     

Urinary undiversion: use in management of radiation induced bladder fistula.

Urinary undiversion was attempted and successful in two patients. The indication for prior diversion in both patients was extensive bladder fistula following pelvic radiation for cancer of the uterine cervix. Function of the urinary system has been essentially normal in both patients during the follow-up period of 6 months to 2.5 years. Review of the literature relevant to reconstruction of the urinary system in adults following previous ileal conduit formation revealed very scanty data, particularly after pelvic radiation. Reported methods are described. Although the experience is limited, ileocystostomy with undiversion of the ileal conduit after pelvic radiation appears not only feasible, but very rewarding for selected highly motivated patients.